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Do not take oral temperatures on preschool children patients with oxygen delirious, confused, disoriented patients comatose patients patients with nasogastric tubes in place patients who have had oral surgery patients who are vomiting or nauseated

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Do not take rectal temperatures on infants or children unless a core temperature is needed patients who have had rectal surgery combative patients

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Abnormal temperatures Fever, febrile, hyperthermia all indicate someone who has an elevated temperature (>100 Fahrenheit). High fever would include anything over 103 degrees Fahrenheit. Moderate fever would include anything 100 – 103 degrees Fahrenheit. Hypothermia (<96F)is subnormal temperature. This can be equally problematic for a person

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Assessing Temperatures With a partner Take both an oral and axillary temperature using a digital thermometer –Record each temperature reading in both Fahrenheit and Celsius using the correct formula Take a tympanic temperature –Document your temperature

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Pulse Wave of blood produced and felt along the artery when the heart contracts and rests ( relaxes) BEATS Can feel at points where the artery is between finger tips and a bony area

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Need to Know Pulse Terms Rate –Number of bests/per minute Rhythm –Regularity of the pulse Volume –Refers to the strength of the pulse Apical pulse –Pulse take at the apex of the heart with a stethoscope

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Pulse Points- NEED TO KNOW 1.Temporal --either side of forehead 2. Carotid- at neck- either side of trachea 3. Apical- at apex of heart 4. Brachial-inner aspect of antecubital space 5. Radial- inner aspect of the wrist 6. Femoral- inner aspect of the upper thigh where it meets trunk-- groin 7. Popliteal- behind the knee 8. Dorsal Pedis -at the top of the foot arch

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Pulse Point Diagram

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Measuring Pulses Measured by index, middle, and ring fingers over pulse point. Do not take with the thumb, since it has a pulse of its own. Count for 30 seconds and multiply by 2, or count for 60 seconds

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Process of taking in O2 and expelling CO2 one respiration consists of –One inspiration –One expiration Please note the following when mearusing each and every respiration: 1.Rate 2.Character 3.Rhythm

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Respirations Each breath includes inspiration and expiration. Measure by observing chest rise and fall. Measured in breaths per minute.

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Respirations Rate – number of breaths/ minute Character –Depth and quality of respirations –Deep-shallow-difficult-stertorous-moist Rhythm –Regularity of respirations

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Assessing Respirations Assess the radial pulse rate of the patient for one minute After the pulse rate have been counted– leave your hand in the pulse position Count the number of respirations- chest rise and fall for one minute Each complete cycle is ONE respiration

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Pulse Oximetry Pulse oximetry is a procedure used to measure the oxygen level (or oxygen saturation) in the blood. It is considered to be a noninvasive, painless, general indicator of oxygen delivery to the peripheral tissues (such as the finger, earlobe, or nose).

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How it works……. Pulse oximetry technology uses the light absorptive characteristics of hemoglobin & the pulsating nature of blood flow in the arteries to aid in determining the oxygenation status in the body There is a color difference between arterial hemoglobin saturated with oxygen, which is bright red, and venous hemoglobin without oxygen, which is darker. with each heartbeat there is a slight increase in the volume of blood flowing through the arteries Pulse Oximetry measures the maximum amount of oxygen-rich hemoglobin pulsating through the blood vessels

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Pain Assessment Pain is subjective Pain is also multidimensional, so the clinician must consider multiple aspects (sensory, affective, cognitive) of the pain experience. the nature of the assessment varies with multiple factors so no single approach is appropriate for all patients or settings.